Health care for the state’s homeless people has never been more critical. Jan Hallam reports.
Pictures: Tony McDonough
Announcements of big government spending projects have become a regular occurrence in these COVID-19 times and as the state gears up for an election next month, the money is flying around from both ends of politics.
In health there has been promised funds by the incumbent government for a range of infrastructure and equipment projects, many in regional areas, mental health and research. The $319 million social housing economic recovery package (SHERP), while not running through the WA Department of Health books, is expected to have long-term positive health impacts for some of the state’s most vulnerable citizens.
The Federal Government’s substantial increase in the Job Seeker payment and the Job Keeper subsidy have been credited for keeping a lid on the unemployment and homeless rates but there is a lot of breath-holding in the community sector as these supports are peeled back in the next couple of months.
Homelessness and rough sleeping in the CBD found controversial prominence during the Perth City Council election campaign in October and, in November, Noongar community leaders and activists marched on Parliament House demanding action on the availability of public housing and the plight of those sleeping rough.
Nowhere to go
Tent cities have sprung up in the Perth CBD and Fremantle’s Pioneer Park, highlighting the urgent need for accommodation for thousand-plus people.
Both sides of politics have pledged action.
For the medical and social support organisations that know this space best, they are bracing for what they expect will be a rocky 12 months to come.
One person who understands well the precariousness of the current situation is Dr Andrew Davies, who leads the Homeless Health Care (HHC) team and is also an integral part of the RPH Homeless Team.
In February 2019, UWA published its evaluation of the first two and half years of the RPH team’s operations. It reported that in that time it had provided 2486 separate consultations during 1812 episodes of care to 1014 patients. The report provides a grim snapshot into the lives and health of people who are living rough on the streets.
“The majority of these patients were not known to HHC prior to their Homeless Team contact, demonstrating this cohort’s disengagement and lack of access to primary care in the community,” the report said.
Other statistics showed that patients had an average age of 44 at their first contact with the service and 86% of them were Australian born. Patients who identified as Aboriginal and/or Torres Strait Islander were overrepresented compared to the general population, accounting for 29% of patients seen by the Homeless Team.
The report flagged that 73% of patients at first contact with the team were rough sleeping:
“For the subset with self-report VI-SPDAT (Vulnerability Index Service Prioritisation Assistance Tool) data, it was found that more than 70% of patients scored above 10 indicating very high levels of vulnerability amongst the cohort.
Multi-morbitities
“Poor health and multi-morbidity are commonplace…[with] health conditions affecting these patients often exacerbated by their experience of homelessness. The most common physical, psychiatric and alcohol and other drug (AOD) related pre-existing conditions upon first contact with the RPH Homeless Team were hepatitis B and C (28%), depression (26%) and methamphetamine use (34%).”
Dr Andrew Davies has been caring for the Perth CBD’s rough sleepers since 2004 and his fledgling Mobile GP service began clinics in 2008
at drop-in centres around the city.
As the years have rolled on and the demand for GP and community nursing has increased, Andrew has broadened the scope of the practice to include a transition clinic and the work on the RPH team.
The RPH team, which is led by emergency medicine specialist Dr Amanda Stafford, is based on a program that has been implemented in 11 hospitals in the UK. Here, HHC GPs, nurses and caseworkers link homeless patients who attend hospital with primary care health services as well as community support and housing services. The idea, of course is to address their social needs alongside their health issues.
It is an opportunity for Andrew and the HHC to make contact with people who can so easily become lost in the bustle and carelessness of the CBD.
The pandemic has given policy makers heightened awareness of the precariousness of these people’s lives. Andrew’s team has been engaged to expand the service with extra outreach services having doctors and nurses accompany outreach workers on their rounds through the streets and to visit people newly rehomed.
Andrew said the outreach work was proving to be particularly useful.
“We are so lucky that one of the outreach workers in this area is indigenous and knows everybody on the street, so we are getting past engagement problems just by association.
“These visits have been a good way for us to see some people who just don’t come in for appointments. The project has been COVID funded and UWA is evaluating it. I’m looking forward to seeing how that goes and that the evidence shows that it’s reducing people’s hospital presentations as we hoped.”
Housing shortage
Housing may be a big part of the solution, but it is not the only element for a successful transition from homelessness to homed.
“Those who have been rehoused in individual housing still have all the health issues and problematic relationships with services, so this visiting service is another piece of the puzzle that creates more options for homeless people to access primary health care.
The West Leederville transition clinic still accounts for about half of HHC’s workload and it offers more discreet general practice for people who are homeless or housed and who just can’t negotiate the mainstream.
Andrew said mental health and drug and alcohol conditions were the main health problems facing homeless people.
“Until about a year ago, what we were seeing most was alcohol dependence. Now meth has finally filtered through into homelessness more, but mental health is the most common – and that means all mental health problems, particularly trauma-based issues.
“The public mental health system tends to deal with psychosis and not much else. So, depression and anxiety and PTSD often fall through the gaps and they end up coming to see us.
“We have upskilled in these areas, but GPs in general have been doing that for years. The physical health issues are mainly complications of drug and alcohol use – it could be anything, but hepatitis C is probably the most common.
“The new direct-acting antivirals are absolutely fantastic – they have made such a difference.”
With significant shifts in government funding and policy, does it give him renewed hope that real change can happen in these people’s lives?
Actions not words
“I’m optimistic by nature. I’ve been working in homeless health care for 17 years now. There have been a lot of announcements and the right things are being said, but let’s actually see it happen because the numbers of people getting stuck on the streets just continues to climb,” he said.
“Once someone has been on the streets for six to 12 months, they have become so damaged psychologically and physically that it is really hard for them to maintain stable housing.”
While Andrew says HHC is currently seeing a lot of regulars, he is bracing for a projected increase in homeless people when special federal funding is removed.
“These supports have kept people from falling completely into homelessness. That said, I reckon it takes about six months from a person losing their job and winding up on the streets because they have social contacts they can rely on for a bit. So, yes, we are worried about the possible blow out.
“An overriding concern for homeless people is permanency and security and it’s that uncertainty that creates a lot of the issues. When you look at the different groups who are homeless, it is those who are chronically stuck on the streets who have the worst health outcomes.
“Those who have a single episode of relatively brief homelessness have the best health outcomes among the homeless cohort. Then there are those who bounce in and out of accommodation and homelessness. These people don’t do well, health wise.”
Respite needed
On Andrew’s wish list (and has been for the past five years) is a respite centre that would help recovery outside of a hospital setting.
“Unfortunately, without a home to stay in, homeless people cannot access services that enable shorter stays in hospital, resulting in high rates of unplanned readmission. A recovery centre can meet those health needs.
“Several US studies have shown that medical recovery centres are responsible for substantial reductions in hospitalisations and hospital re-admissions. Such a service would save the health system valuable taxpayers’ money.”
When times get tough, and in this area of healthcare they are numerous, what keeps staff going is the success stories.
“We can’t control bad outcomes particularly well, but the good outcomes are just phenomenal,” Andrew said. “And that’s what keeps you going, in spite of everything else. All the doctors, nurse practitioners and nurses
say the same.”
HHC now numbers seven doctors, two nurse practitioners and about 25 nurses plus a couple of administration people.
“Just five years ago we were less than 10 people.”
And as Andrew comments, he’s not going to be short of work anytime soon.
ED: Authorised pictures supplied by Raw Image.